MED EMERGENCY / URGENCE ISSN 2222-9442

Emergency responses and triage of

victims in case of natural disasters
and nuclear biological or chemical
menaces
Le télédiagnostic, un concept
adapté à l’évaluation de la
contamination accidentelle ou
intentionnelle d’une ressource en
eau

Chloroquine overdose
Coronary spasm
Intérêt de l’échocardiographie en pré-
hospitalier
Brûlures et atteintes caustiques oculaires
HIV and AIDS: global summary and basic
Trimestriel

facts

Endorsed by December 2014 - N°21

 ORIGINAL ARTICLE

Emergency responses in case of mass casualties’

different big bang incidents: the Paris Fire
Department prehospital medical care approach

Lefort H, Travers S, Bignand M, Mihai I, Béguec F, Calamai F, Hersan O, Tourtier JP, Carpentier JP. Emergency
responses in case of mass casualties’ different big bang incidents: the Paris Fire Department prehospital medical care approach.
Med Emergency, MJEM 2014; 21:3-9.
Keywords: Big-bang, disaster preparedness, mass casualties, resuscitation, terrorist, toxic, triage

ABSTRACT
Introduction: Taking into consideration the natural disasters, the industrial and terrorist attacks had changed significantly with
time. The idea of terrorist threats such as chemical biological radiologic or nuclear (CBRN) have determined the authorities
to change and adjust their approach.
Methods: Through the experience of the Fire Brigade of Paris (BSPP), we focus on the emergency services organization
during a major event and on the triage of the victims, whether of a natural disaster or exposed to the CBRN.
Results: The new approach is based on a very clear and very well organized emergency care support, a very well organized
commanding network, and last but not least a very well prepared logistic support.
Conclusion: The willingness and the necessity to anticipate the occurrence of such risks is materialized by the systematic
well organized and clearly assigned functions: transport, triage, medical care, and evacuation of the victims. All of which
are coordinated by the medical rescue direction.

Authors’ affiliation:
Correspondent author: Hugues LEFORT, MD
Emergency Medical Service, Fire Brigade of Paris, Paris, France
1 place Jules Renard, 75017, Paris
hdlefort@gmail.com

Lefort H, MD1, Travers S, MD1, Bignand M, MD1, Mihai I, MD1, Béguec F, RN1, Calamai F, MD1,
Hersan O, MD2, Tourtier JP, MD1, Carpentier JP, MD3
1. Emergency Medical Service, Fire Brigade of Paris (BSPP), France
2. SMPM, Military Health Services, Paris, France
3. Military Paramedics School, Toulon, France

Article history / info: Dr Hugues Lefort

Category: Original article
Received: Nov 5, 2014
Revised: Nov 19, 2014
Accepted: Nov 26, 2014

Conflict of interest statement:

There is no conflict of interest to declare

Med Emergency, MJEM – 2014, No 21 3

 ORIGINAL ARTICLE
INTRODUCTION
The number of natural disasters has increased three times fold
in fifteen years, affecting more than 200 million people per
year and resulting in 100.000 deaths. The most vulnerable to
natural disasters are the developing countries due to increasing
population, a disaster-favoring environment, most often in
a logistic and medical care undeveloped context. On the
other hand, the number of technology related disasters (fires,
explosions, road accidents) is constantly increasing since the
1970s.
Whether accidental or intentional the chemical biological
radiologic or nuclear (CBRN) threats are more and more
present. Some countries haven’t yet signed the Chemical
Weapons Convention (CWC). The CWC aims to eliminate an
entire category of weapons of mass destruction by prohibiting
the development, production, acquisition, stockpiling,
retention, transfer or use of chemical weapons by States Parties.
States Parties, in turn, must take the steps necessary to enforce
that prohibition in respect of persons (natural or legal) within
their jurisdiction (www.opcw.org). Despite the Organization for
the Prohibition of Chemical Weapons (OPCW) efforts, some
countries such as Libya and Syria still have stocks of chemical
weapons (Sarin, VX, Mustard gas, etc.). Mustard was used in
Japan in July 1994 (Matsumoto city) and in March 1995 (Tokyo
metro). In September-November 2001, anthrax-containing
envelopes distribution in the United States denoted the first
attempts of biological terrorism. Since 1993, the international
Atomic Energy Agency (IAEA) has recorded more than 600
cases of illegal sale of radioactive elements. Undergoing
investigations on the terrorist network confirm their interest
in nuclear energy release and radioactive dispersion gears. A
source of cesium 137 destined to explode was found in a park in
Moscow in 1996.
The 9-11 attacks in the US are an example of hyper terrorism:
a terrorist act based on the controlled use of new technologies
resulting in hundreds of victims [1;2]. Between 1986 and
September 2001, many proofs confirm the growing interest of
terrorists for controlling CBRN weapons. Attacks of this kind
occurred in Iraq between January and April 2007 (explosives
containing chlorine). The attacks in Madrid in March 2004,
in London in July 2005 and the Mumbai hostage situation in
December 2008 confirmed the presence of both international
and European terrorist networks. The severity of such acts
is mainly due to the toxicity of the products involved, the
way contamination and the persistence of the product, all
which determines an exponential increase in the number
of casualties in time, if actions of the first responders on the
ground would be inappropriate. New reality of the 21st century,
the acts of hyper terrorism are designed to make a large
number of victims by touching several locations in a very short
time and/or to destabilize permanently or for a long period of
time a community or a state.
The management of these old and new risks is a matter for
experts and requires anticipation, a continuous search for
practical solutions [3] in addition to special training. However
few triage tools are now validated [4;5]. We present the initial
response of the Fire Brigade of Paris (BSPP) in mass casualties’
different big bang incidents.
4 Med Emergency, MJEM – 2014, No 21
Triage, an essential act in mass
casualties
In many countries, in case of mass casualties, triage is the task
of para-medical personnel and not the medical physicians’. In
situations like this, there is an imbalance between the available
medical resources and the number of casualties. The goal of
the triage is to save the highest number of victims. Historically,
triage is the diagnostic medical action allowing the recognition
of the injury and its consequences on the vital functions. The
triage starts on-site, during the search and rescue during the
first medical care which includes the categorization of the
victims, in order to prioritize their treatment and evacuation.
The concept of triage is inherited from the military doctrine,
it evolves in catastrophic situations, and it is applied to the
physical and psychological trauma patients [2;5;6]. In France,
the French Society of Disaster Medicine (Société française de
médecine de catastrophe or SFMC) is the one responsible for
the triage classification, similar to the NATO classification [7;8]
(Table 1). The organization of the medical response on-site is
based on the first rescuers’ dual triage, performed on the site
and that classifies the victims as either absolute emergency
(AE) or Relative Emergency (RE).
Within the advanced medical post (Poste medical avancé
or PMA), the triage is the responsibility of the chief physician
(Directeur des secours médicaux or DSM) who will classify
the absoluted emergency (AE) in: immediate emergency (IE),
first emergency (U1) or functional emergency (FE), the relative
emergency (RE) in: second (U2) and third emergency (U3).
He will add a new category, the expectant emergency (EE).
Table 1 describes more accurately this categorization by
comparing it with the Anglo-Saxon sorting resumed by NATO.
Anticipating reality disaster
medicine: contingency plans
From red plan to ORSEC-NoVi plan (Civil Security
Response - Mass Casualty):
Through the years, faced with mass casualty events, the
Emergency Medical Service (EMS) of the BSPP has developed
a response method adapted to this such situation: the Red
Plan. This plan is “the implementation of a pre-prepared
doctrine with means and personnel are likely to deal with
the consequences of a natural, technological or social
event causing or likely to cause mass casualties, so that the
emergency response resources” meets the “acute increase in
healthcare needs”. The red plan was conceived in the field of
the operational military expertise, has gradually developed
and improved in time because of numerous disastrous, mass
casualties events that occurred in the Parisian region in the
last four decades. The Red Plan has contributed significantly
to improving the effectiveness of emergency care response.
It is based on a policy of action, command and control of all
responders: police, firefighters officers, medical personnel,
rescue associations, private ambulances, guaranteeing its
effectiveness. It is always coordinated by a DSM of BSPP in close
cooperation with the EMS of the four departments of Paris
 ORIGINAL ARTICLE

Direct triage Medical Medical Triage

Short
by first Triage Management Evacuation Anglo-Saxon
definition/description
responders SFMC (OTAN)

Direct transfer to a
IE T1
Life threatening vital Pre-hospital resuscitation team hospital facility best
Immediate = Mention of Immediate
prognosis for one victim suited to the
Emergency Emergency (IE)
unstable patient

Other T1
AE Pre-hospital resuscitation team = U1 within 4 hours
Alarming vital prognosis.
Absolute U1 for 3-5 victims
Surgical intervention Transfer by non
Emergency First T2
within the next 6 hours medicalized (or
Emergency "Degraded" and adapted = Delayed Emergency
at best medicalized convoy)
medicalization = U1 between 4 to 6
to a specific hospital
hours
facility after
Not taken into
FE Wounds of the eyes, stabilization
consideration
Functional hand, face, soft tissue On-site medicalization
Categorized in T2
Emergency near limb…
= Delayed Emergency
Non medicalized
Invalid victims. T2
U2 transfer, after
Non-threatening vital Supine or semi-sitting transfer in = Delayed Emergency
Second stabilization, to a
prognosis if managed a first aid vehicle and some T3
RE Emergency remote hospital
within 18 hours = Minimal Emergency
Relative from the event
Emergency
Transfer by public
U3 Valid victims.
Management by the first transportation to a T3
Third Crippled and mentally
responders and associations remote facility from = Minimal Emergency
Emergency injured
the event
T4
Comfort care and support Left on site,
severely injured patient = Expectant
EE services. Possible management medicalization
requiring long and heavy
Expectant Emergency within one hour following following
treatment with low After damage control,
or deceased “damage control” for management of the
survival rate potential requalification
requalification in AE AE
in T1

Table 1: Triage and patient evacuation of according to the French Society of Disaster Medicine (SFMC) and a brief correspondence with the Anglo-Saxon triage (NATO).

and Ile-de-France provided with the greatest resource of pre-

hospital healthcare responders.
Learned lessons from feedback experience were taken into
account, thus creating the 2004-811 Law 13 August 2004 on the
modernization of Civil Security. The new generation general
rules for the organization of Civil Security Response (ORSEC)
integrate the ORSEC-Mass casualty (ORSEC-NoVi), as response
to the catastrophic mass casualty events, instead of the original
“Red Plan”.
The ORSEC-Novi plan has three objectives:
1. Extract the victims from the hostile environment
2. Provide support and treatment for the victims
3. Mobilize departmental resources to ensure an appropriate
response.
In France the ORSEC-NoVi plan is the reference
plan for the mass casualty management. This
management is characterized by grouping the
medical services in and around the PMA and
performing at this level the medical triage (Figure 1).
The AU victims will receive prehospital treatment and will be
transported to a hospital after stabilization. The RE victims will
be transported by para-medical teams to different emergency Figure 1: Red Plan of «Cité du labyrinthe», April 14, 2011
services if possible away from the site of the disaster. And that, PoliceHeadquarter\BSPP\BurnerP©

Med Emergency, MJEM – 2014, No 21 5

 ORIGINAL ARTICLE

in order to avoid the overcrowding of the nearby hospitals - The second stage, the volume and nature are based on
already particularly flooded, in case of a disaster, by “walking- information collected by the first responders. Predetermined
in” patients that have not been filtered through the PMA [9-11]. groups and modules might be sent, depending on the needs
This was the case after the explosion of the AZF factory in (e.g. search and rescue, PMA, evacuation group, etc.)
Toulouse in France on 21st September 2001.
The criteria to intervene depend on the actual or potential The Red Plan Alpha: a Parisian specificity
number of victims, type of disposed emergency services and
the level of their possible involvement. When putting in action France has not yet been faced with what is called acts of hyper
an ORSEC-NoVi plan, it is essential to corroborate the available terrorism like the ones that took place in Tokyo in 1995 [13;14],
medical means to the anticipated number of victims. Duncan Madrid in 2004, London in 2005 or Bombay in 2006 [15-17],
et al., interviewed [12] a number of English experts in disaster targeting massive destruction, on multiple sites and with
medicine. Their goal was to establish, by using the Delphi possible use of CBRN substances [1].
method, whether there was a consensus concerning the Facing these new menaces, the authorities of the city of Paris
232 items involved when managing 100 victims. At the end, have requested from the BSPP, in collaboration with the
23% of the interviewees reached an agreement on 54% of the four EMS d’Ile de France, to be able to deploy simultaneously
questioned items (n-134). This anticipation can also avail the and on different locations the necessary means to ensure the
concept of multiplying coefficient following the retrospective command and control of at least four mass casualty sites, one
experience of such situations: the ratio between the initial and of which may require the involvement of NRBC means, while
the final number of victims. The number of casualties, being maintaining a basic efficient operational activity. The Red
the unique variable, it should be completed by qualitative Plan Alpha (Figure 2), put in place in 2007, aims to address
criteria: the risk of mass influx of casualties, multi-site and terrorists
- The deployment or organization difficulties. attacks and bombings by restricting the initial rescue means
- The technical complexity of the intervention: incarceration involvement in order to be able to respond proportionately on
contamination. several sites [18;19]. It also aims to preserve the operational
- The vulnerability of the structure involved: a hotel, a services of emergency units and anticipate the potential risk
hospital, a nursery, a nursing home, a school, or more of another attack on the original site. In this management of a
generally, any place open to the public. large number of victims, the triage closest to the event must be
- The potential evolution of the event. conducted according to the principle of disaster medicine and
The resources’ deployment is done in two stages: the distribution of victims must be done to the proper hospitals.
Thus, the term of “reinforcement” employed in the ORSEC-NoVi
- The first stage, available without delay in a predetermined Zonal plan can then be implemented to enable the concerned
manner: the deployment of means and personnel able to area to benefit from all the necessary resources (means of
intervene promptly. interventions, hospital resources, etc.). Last, but not least, the
patients vital signs monitoring must be registered, on-site and

At least 4 emergency engins for each of the multiple victims locations,

One of wich might need involvement of the CBRN means

Dedicated radio channel

Explosion and/or
terrorist attack with
multiple victims IE
THE RED ‘ALPHA’ PLAN

«I request 1 victim for

deploiment of the each medical
Red Alpha team
Plan ,TrocadéroSqua
re »

U1

AU 3 -5 victims for each

medical team

AU
RU
RU
U2
100 m

U3

Gathering Triage Evacuation

officer officer officer

Gathering Area Engins: Evacuation Area Engins:

2 first–aid engins and FBP Triage Area Engins : 1 radio-connection engin,
stretcher-bearersE 4 first-aid engins,10 associations engins and
1 van, 6 medical engins
engins for multiple victims transportation
Dessins : René Dosne

Figure 2: Modality of deployment of Red Alpha Plan. BSPP©

6 Med Emergency, MJEM – 2014, No 21

 ORIGINAL ARTICLE

Figure 3: Deployment of yellow plan. The PIRATOX plan for the BSPP (Paris) and its suburbs. BSPP©
during the treatment and transport, on an assigned sheet or its
biometric equivalent; the use of a numeral system [20] to follow
the victims from the disaster site to the hospital proved to be of
great help since it has been used in the Parisian region for years.
Specific response to a nuclear, radiological or
chemical threat.
the multitude of attack sites prevented the completion of a pre-
hospital triage.
In Saint-luke hospital, 35% of victims arrived all by themselves,
24% by taxi and 7% by ambulance. Three patients in
cardiopulmonary arrest were transported to Saint-Luke’s
Hospital in the hour following the attack and could not be
resuscitated.

The Circulars 007, 700, 747 and 800 of the General Secretariat for The CBRN-e (Yellow Plan) has the objective to manage quickly
Defense and National Security (SDGN) for the French national the victims using these four actions:
employment doctrine rescue services and care to the terrorist - Fast extraction of all persons present in the affected area
actions with chemical or radiological contents provide an which expose them to an imminent
institutional response like other countries [21-24]. The French - Visual triage to differentiate between involved victims, the
authorities have elaborated, based on these circular, a CBRN-e injured or those showing sign of possible exposure.
Governmental Plan. Its goal is to ensure rapid, methodical and - Victim management by providing early treatment (use of
coordinated deployment of material and personnel resources antidote) and urgent decontamination.
in the areas of defense facing nuclear or chemical exposure. It - Emergency care and thorough decontamination.
also coordinates the commitment of individual and resources,
as part of a major operation to contain the chemical or
radiological area causing many casualties.
The involvement of medical staff under protective equipment
in a contaminated zone, considered inappropriate for a long
time, allows a minimal medicalization before complete
decontamination intended solely to ensure the survival of the
victims until the end of this step in accordance with CBRN-e
Plan.
Established in 2007, this CBRN-e Government Plan is broken
down from the yellow plan by the BSPP and provides an on-
site solution (Figure 3) aiming at limiting the risk of spread of
contamination and simultaneously providing medical care
to traumatized victims. In Tokyo, sarin has been spilled in the
wagons and the passengers exited the stations along the way.
This spontaneous evacuation of victims by the witnesses and Figure 4: Medicalization of an intubated patient in an exclusion zone (drill).
BSPP\DSan ©

Med Emergency, MJEM – 2014, No 21 7

 ORIGINAL ARTICLE

Victims
IMPLICATED VISUAL and
TRIAGE Sieve « responders »
Gathering Points

VALIDS
INVALIDS

DECONTAMINATION CHAINS
VICTIMS

Undressing 1st layer Undressing

Emergency decontamination Emergency decontamination
Brief dressing Medical treatment Sieve
VALIDS responders
VALIDES INVALIDS
Undressing
Emergency decontamination
Red Plan Shower
or Red Alpha Plan Dressing

Figure 5: Triage on yellow plan. BSPP©

The US military recommends a triage adapted according to the of the Director of Medical Rescue (Directeur des opérations
chemical involved [25] but its implementation is not simple, and de secours or DOS) or the Commander of Rescue Operations
it might not be applied to the victims of an attack whose age (Commandant des operations de secours or COS). It is the
and medical intercurrent conditions are more variable. same in case of an attack involving radiological materials. Apart
from a few cases of a huge radiation exposure with fast clinical
In France, it was long believed to be inappropriate to provide
signs, most contaminated victims show no clinical sign in the
care before complete decontamination; that was the case
relief operations. The CBRN expertise is needed to assess the
till the late 90’s. The French policy (civil and military) for
intensity and type of radiation that will affect time-to-onset of
management of chemical casualties has evolved [25]. The
symptoms that are often delayed [6-8;32].
objective is an emergency decontamination with a minimum
medicalization aiming solely to allow the survival of victims
until the end of the complete decontamination.
Conclusion
The decontamination becomes a priority particularly in
the presence of a persistent toxic. The initial screening is Triage is a necessary action in the case of a disaster. Its aim
performed by rescuers and visually separates the clean victims is to save the maximum number of victims using all available
from the contaminated ones (showing sign and symptoms of means. Developing a back-up plan ahead of time can anticipate
exposure by chemical or radiological agents). Only the patients an institutional response to CBRN-e or in the case of a natural
showing signs and symptoms of intoxication or traumatic disaster. The expert involvement is required both in the
injury are grouped in the Victim Assembly Area (Point de design and development phase, during drills and definitely in
regroupement des victimes or PRV) (Figure 4), relevant ones emergency responses to mass casualties’ events.
are being grouped in the Assigned Gathering Area (Point de
regroupement des impliqués or PRI). Both undressing and
urgent decontamination take place only in the PRV. The aim
is to provide the essential emergency medical care to allow
the patient’s survival until complete decontamination. For
example, control a hemorrhage, administer antidotes and
place in a recovery position. Intubation should be seriously
evaluated taking into account the limitations it poses to the
decontamination step. The resuscitation, intra-veinous access,
ventilation and intubation can be still be performed using
CBRN protection [26-31]. The sorting between contaminated
or not contaminated is more difficult, especially when clinical
signs are not obvious (Figure 5). This medical classification is
performed using the skills of CBRN experts under the orders

8 Med Emergency, MJEM – 2014, No 21

 ORIGINAL ARTICLE

REFERENCES

1. Jenkins JL, McCarthy ML, Sauer LM, Green GB, Stuart S, Thomas Tl et al. Mass-casualty triage ; Time for an evidence-based approach.
Prehosp Disaster Med 2008; 23:3-8.
2. Dudaryk R, Pretto EA. Resuscitation in a multiple casualty event. Anesthesiol Clin 2013; 31:85-106.
3. Hinton Walker P, Garmon Bibb SC, Elberson KL. Research Issues in Preparedness for Mass Casualty Events, Disaster, War, and Terrorism.
Nurs Clin North Am 2005; 40: 551-64.
4. Dara SI, Farmer JC. Preparedness lessons from modern disasters and wars. Crit Care Clin 2009; 25:47-65.
5. Kilner TM, Brace SJ, Cooke MW, Stallard N, Bleetman A, Perkins GD. In ‘big bang’ major incidents do triage tools accurately predict clinical
priority?: A systematic review of the literature. Injury 2011; 42:460-8.
6. Adnet F, Maistre JP, Lapandry C, Cupa M, Lapostolle. Organisation des secours lors de catastrophes à effets limités en milieu urbain. Ann
Fr Anesth Reanim 2003; 22:5-11.
7. Ramesh AC, Kumar S. Triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, or nuclear
agents. J Pharm Bioallied Sci 2010; 2:239-47.
8. Macintyre AG, Christopher GW, Eitzen E, Gum R, Weir S, DeAtley C et al. Weapons of mass destruction events with contaminated casualties:
effective planning for health care facilities. JAMA 2000; 283:242-9.
9. Laurent J, Richter F, Michel A. Management of victims of urban chemical attack: the French approach. Resuscitation 1999; 42:141-9.
10. Baker DJ. Critical care requirements after mass toxic agent release. Crit Care Med 2005; 33:S66-74.
11. Tucker JB. National health and medical services response to incidents of chemical and biological terrorisme. JAMA 1997; 278:362-8.
12. Duncan EA, Colver K, Dougall N, Swingler K, Stephenson J, Abhyankar P. Consensus on items and quantities of clinical equipment required
to deal with a mass casualties big bang incident: a national Delphi study. BMC Emerg Med 2014; 14:5.
13. Okumura T, Takasu N, Ishimatsu S, Miyanoki S, Mitsuhashi A, Kumada K et al. Report on 640 victims of the Tokyo subway sarin attack. Ann
Emerg Med 1996; 28:129-135.
14. Okumura T, Hisaoka T, Yamada A, Naito T, Isonuma H, Okumura S et al. The Tokyo subway sarin attack - lessons learned. Toxicol Appl
Pharmacol 2005; 207s:471-6.
15. De Ceballos JP, Turégano-Fuentes F, Perez-Diaz D, Sanz-Sanchez M, Martin-Liorente C, Guerrero-Sanz JE. 11 March 2004: The terrorist
bomb explosions in Madrid, Spain - an analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest
hospital. Crit Care 2005; 9:104-11.
16. Redhead J, Ward P, Batrick N. The london attacks-response: Prehospital and hospital care. N Engl J Med 2005; 353:546-7.
17. Lockey DJ, Mackenzie R, Redhead J, Wise D, Harris T, Weaver A et al. London bombings July 2005: the immediate pre-hospital medical
response, Rescuscitation 2005; 66:ix-xii.
18. Horne S, Vasallo J, Read J, Ball S. UK triage – An improved tool for an evolving threat. Injury 2013; 44:23-8.
19. Bogle, LB, Boyd JJ, McLaughlin KA. Triaging multiple victims in an avalanche setting: The avalanche survival optimizing rescue triage
algorithmic approach. Wilderness Environ Med 2010; 21:28-34.
20. Travers S, Bignand M, Raclot S, Domanski L, Tourtier JP. Difficulties of triage in mass casualties incident. Injury 2013; 44:1965-6.
21. Lyle K, Thompson T, Graham J. Pediatric mass casualty: triage and planning for the prehospital provider. Clin Ped Emerg Med 1999; 10:173-85.
22. Potin M, Sénéchaud C, Carsin H, Fauville JP, Fortin JL, Kuenzi W et al. Mass casualty incidents with multiple burn victims: rationale for a
Swiss burn plan. Burns 2010; 36:741-50.
23. Vinson E. Managing bioterrorism Mass casualties in an emergency department: Lessons learned from a rural community hospital disaster
drill. Disaster Manag Response 2007; 5:18-21.
24. Aylwin CJ, König TC, Brennan NW, Shirley PJ, Davies G, Walsh MS et al. Reduction in critical mortality in urban mass casualty incidents:
analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet 2006; 368:2219-25.
25. Dorandeu F, Blanchet G. Chemical warfare agents and terrorism. Med Catastrophe Urg Collectives 1998; 1:161-70.
26. Schumacher J, Weidelt L, Gray SA, Brinker A. Evaluation of bag-valve-mask ventilation by paramedics in simulated chemical, biological,
radiological, or nuclear environments. Prehosp Disaster Med 2009; 24:398-401.
27. Ophir N, Ramaty E, Rajuan-Galor I, Rosman Y, Lavon O, Shrot S et al. Airway control in case of a mass toxicological event: superiority of
second-generation supraglottic airway devices. Am J Emerg Med 2014; doi: 10.1016/j.ajem.2014.08.067.
28. Castle N, Bowen J, Spencer N. Does wearing CBRN-PPE adversely affect the ability for clinicians to accurately, safely, and speedily draw
up drugs? Clin Toxicol (Phila) 2010; 48:522-7.
29. Castle N, Owen R, Hann M, Clark S, Reeves D, Gurney I. Impact of chemical, biological, radiation, and nuclear personal protective equipment
on the performance of low -and high- dexterity airway and vascular access skills. Resuscitation 2009; 80:1290-5.
30. Castle N, Pillay Y, Spencer N. Insertion of six different supraglottic airway devices whilst wearing chemical, biological, radiation, nuclear-
personal protective equipment: a manikin study. Anaesthesia 2011; 66:983-8.
31. Wedmore IS, Talbo T, Cuenca PJ. Intubating laryngeal mask airway versus laryngoscopy and endotracheal intubation in the nuclear,
biological and chemical environment. Mil Med 2003; 168:876-79.
32. Leslie CL, Cushman M, McDonald GS, Joshi W, Maynard AM. Management of multiple burn casualties in a high volume ED without a verified
burn unit. Am J Emerg Med 2001; 19:469-73.

Med Emergency, MJEM – 2014, No 21 9